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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />Iw1'V-r%erUN1JAtiL1:: rtKmir CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br />JOB ADDRESS 1 2601 N Alpine RD cn-Y/ZlpStockton, CA 95212 <br />CROSS STREET Handel Rd APN 06114047 PARCEL SIZE 6 0 .7 6 LAND USE APPLICATION # <br />JOWNERNAME Joe Gotelli & Sons <br />OWNERADDRESS _9189 N Ashley Ln <br />CONTRACTOR Purviance Drillers, Inc <br />PO Box 64 <br />CONTRACTOR ADDRESS <br />n/a <br />SUBCONTRACTOR ADDRESS <br />LICENSE )Q<C-57 ❑ C-61 ❑ D-09 7 Other <br />CITY/STATE/ZIP <br />. PHONE209 031 2740 <br />Stockton,CA 95212 <br />PHONE209-887-3554 <br />CITY/STATEOP Linden, CA 95236 <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 377923 EXPIRATION DATE 7/ 31 / 2 3 <br />DOMESTIC WELL SAMPLING: - General Mineral/Coliform Bacteria (4391) .- Dibromochloropropane (4392) Arsenic (4393) <br />SC Received <br />Info B <br />INTENDED USE omestidPrivate ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />Permit! <br />Service Request # Invoice # Well ID# <br />0 Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />I <br />0 Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />r- <br />T <br />❑ Out -Of -Service Well ❑Out-OfService Well Renewal ❑ Cross -Connection RepairFC� <br />❑ New Pump Pump Replacement 11 Pump Repair ❑Raise Well Casing <br />WELL CONSTRUCTION A1V j0.Qq O <br />Drilling Method <br />❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other `\aameter <br />Proposed Well Depth ft Excavation in diameter u Open Bottom ❑ Gravel Pack/G C <br />❑ Conductor <br />Casing in diameter / Conductor Casing Depth ft G jy <br />Ty <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag'5-10 gal water) ❑ Sand Cementsack <br />I water <br />❑ Bentonite (20% solids) 0 Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick <br />in 0 Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP Pump Set _ ft Standing Water Level _l(: ? ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />DEPARTMENT USE ONLY <br />Application Accepted By I Z Z Date Area -V-/ r�� Employee ID# 1 f 4 1l1 I<. i <br />Grout Inspection By 4 Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date j�0 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ Amount <br />Cash Remitted Dat <br />Permit! <br />Service Request # Invoice # Well ID# <br />t <br />Page] oft Well / Pump Permit <br />T <br />